Shruthi Srinivas, MD - Best of the Best in Pediatric Surgery 2024

Brittany, who do we have next? All right, so next, we're moving on to BAPS, and first we have Doctor Shruti Stravinus from Nationwide Children's Hospital with the work on outcomes from colonic pull-through for cloacal atrophy that differ by colon length, a multi-institutional study. So here we go. Thank you for the opportunity to present today. On behalf of Nationwide Children's Hospital and the multi-institutional Pediatric Colorectal and Pelvic Learning Consortium, we'd like to share our study on how outcomes from colonic pull-through for cloacal atrophy differ by colon length. We have no disclosures. Collial atrophy is a rare congenital abnormality involving a grouping of anatomical variations. It affects approximately 1 in 200,000 pregnancies and occurs along a spectrum of severity. Over time, the management of cloacal atrophy has evolved and survival has improved. However, the initial surgical management remains the same and is focused on drainage with an end colostomy or ileostomy and drainage of the bladder. As children grow, the opportunity for reconstruction emerges with improved survival. A larger focus has been placed on reconstructive outcomes. From a colorectal standpoint, the main question has been whether or not a patient should have an endo stoma or if they're a candidate for a pull-through procedure. Early studies described the pull-through as a success, but were limited in cohort size. These initial studies resulted in a great deal of popularity of the colonic pull-through. However, it's unclear whether pull-through remains heavily utilized today. Firstly, we aim to understand whether colonic pull-through remains utilized in patients with coal atrophy. Secondarily, we aim to understand if there are specific factors that are associated with cleanliness following pull-through. To accomplish this, we utilized a multi-institutional collaborative across the United States. This allowed for contribution from 11 major pediatric hospitals over a 10-year time period. We performed a retrospective cohort study of all patients with collical atrophy. We collected data on their demographics, operative course, and cleanliness, which was defined for standard terminology as one or fewer accidents per week. There were a total of 98 patients with a diagnosis of cloal atrophy. All patients underwent an initial stoma creation at a median age of 2 days. For those that underwent pull-through, the median age at pull-through was 1.3 years. Of the 98 patients in the cohort, only about 29% received a pull through. There were 5 patients that required a redo Stoma for various reasons. This leaves 24% of the initial cohort who continue to use their pull-through. Of these, the majority of patients are not clean. This is 16% of the total cohort and almost 70% of children still using their pull-through. Only 7 patients in the cohort are clean following their pull-through. And finally, only 1 patient is continent or not having accidents without the use of bowel management. This represents an overall successful pull-through rate of 7%. Roughly 21% of the population has an unsuccessful pull-through, meaning they're not clean or they went back to an ostomy. We then compared these two subgroups to one another. Two factors have been theorized to contribute to success following pull through. The first is the ability to form solid stool. This was not different between our successful and unsuccessful pull through groups. The second is the preoperative length of colon, which is measured using contrast enema studies. The group with successful pull through had over double the preoperative colon length compared to the unsuccessful pull-through group. This demonstrates the first association between a longer colon length and a greater chance of success following pull through. In summary, in a multi-institutional sample, we demonstrate that most children with collacal atrophy will keep their stoma indefinitely. Of the children that undergo a pull-through, only a small percentage are able to be cleaned for stool postoperatively. A longer colon length correlates with higher success post pull-through. Overall, this suggests that colonic pull-through can remain effective for children with pollical atrophy, but that it may be selectively offered to children with an adequate colon length. Further prospective studies are necessary to understand the impact of selective pull-through on outcomes from cloacal atrophy. Thank you to my lab and to our collaborative partners for their help on this project, and we're happy to discuss further. Hey guys, thanks for, thanks for the paper. That was interesting. I have a question. Um, has this Affected, I mean, Richard, have you started doing the operation differently now, given the data on this paper? Oh, you're muted. We don't hear you. What we can do if we can't get the audio working, um, I don't know if your microphone is on or not. Try again. How about now? Yeah, um, Todd, thanks for the question. I mean, I think one of the main drivers of this paper was because there was this perception that every child with a clerical atrophy should get a pull-through. And we had asked the fellows at, at the, at the meetings and they were saying that, and, and my sense was that it's really the exception rather than the rule that actually does well with the pull-through. And um there was a urology collaborative group, um, that did a similar thing looking at, you know, the, how many kids are actually using a urethra. And I think one of the big problems is that people who work at places like us stand up doing a whole bunch of APRs for kids who are not happy because they're leaking all the time. And so it's really to try and avoid that. Um, thought that every child with cloacal atrophy should be getting a pull-through and, and they've really got to prove that they're going to do well. So we, we test them with bowel management through their stoma to see that they're going to be clean and then we'll offer them a pull-through, but it's really important that we are thoughtful about who we offer reconstructive surgery to, I think. So it's a two-part conclusion. One, don't always jump to a pull-through. And two, if you do, are gonna do a pull-through, it may be that longer colons may give you a better outcome, but still, it's pretty poor. Yeah, I mean, I think with longer colons and good preparation, you know, we have patients who can be clean, but I think it's the exception rather than the rule is, is the thing. And I think counseling families upfront. And having good expectations is probably key. Awesome. All right. I think there's some questions for you in the chat. Um, Shruti, if you can, um, answer those by text, and then we'll be, um, going to the polls soon. All right, thanks, guys. Thank you